The nurse receives a client from the post-anesthesia unit with a new onset of sinus tachycardia and a heart rate of 118 beats per minute. To which reasons does the nurse relate the increased heart rate? (Select All that Apply.)

Anxiety

Sleep

Fever

Hyperglycemia

Blood loss

Answer and Explanation

Correct Answer : A,C,E

A. Anxiety:

Anxiety can lead to an increased heart rate due to the activation of the sympathetic nervous system. When a person is anxious, their body releases stress hormones like adrenaline, which can stimulate the heart to beat faster. This increased sympathetic activity can cause sinus tachycardia, where the heart rate is faster than normal.

B. Sleep:

While sleep can affect heart rate variability, causing fluctuations in heart rate during different stages of sleep, it typically does not cause a significant and sustained increase in heart rate like sinus tachycardia. Sleep is more likely to influence heart rate patterns rather than directly cause sinus tachycardia.

C. Fever:

Fever, especially in response to infection or inflammation, can lead to an elevated heart rate. The body's response to fever includes increased metabolic activity, which can raise the heart rate as part of the physiological stress response. Fever-induced sinus tachycardia is a common finding in individuals with infections.

D. Hyperglycemia:

While hyperglycemia (high blood sugar levels) can have cardiovascular effects over time, such as contributing to atherosclerosis and heart disease, it is not typically a direct cause of sinus tachycardia. Sinus tachycardia is more commonly associated with acute stressors like anxiety, fever, or hypovolemia (such as from blood loss).

E. Blood loss:

Significant blood loss, such as during surgery or due to trauma, can result in hypovolemia, where there is a decrease in blood volume circulating in the body. In response to hypovolemia, compensatory mechanisms kick in, including an increase in heart rate (sinus tachycardia), to maintain blood pressure and perfusion to vital organs.

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Correct Answer is ["1712.32"]

Explanation

To calculate the client's total intake for the 8-hour shift, we need to convert all the volumes to milliliters (mL) and then add them together. Here are the given volumes and their conversions:

1,000 mL 0.9% sodium chloride IV (no conversion needed)

One 6-oz cup of coffee:

6 oz * 29.5735 (conversion factor for oz to mL) = approximately 177.44 mL

6 oz of water:

6 oz * 29.5735 = approximately 177.44 mL

One 180-mL bowl of soup (no conversion needed)

3 oz of flavored gelatin:

3 oz * 29.5735 = approximately 88.72 mL

3 oz of ice cream:

3 oz * 29.5735 = approximately 88.72 mL

Now, let's add up all the volumes:

1,000 mL (IV fluid) + 177.44 mL (coffee) + 177.44 mL (water) + 180 mL (soup) + 88.72 mL (gelatin) + 88.72 mL (ice cream) = 1,712.32 mL

Therefore, the nurse should document the client's total intake for the shift as approximately 1,712.32 mL.

A. " I will have canned chicken noodle soup with crackers and an apple for lunch." B. "I will have a ham and cheese sandwich for lunch." C. "I will have a BLT and a side salad with cheese and croutons for lunch." D. "I will have a baked potato with broiled chicken for dinner."

Correct Answer is D

Explanation

A. "I will have canned chicken noodle soup with crackers and an apple for lunch": Canned soups are often high in sodium, and crackers can also contribute to sodium intake. This meal choice would not align with a low-sodium diet.

B. "I will have a ham and cheese sandwich for lunch": Processed meats like ham and cheese can be high in sodium, especially if they are not low-sodium options. This choice may not be suitable for a low-sodium diet unless specific low-sodium products are used.

C. "I will have a BLT and a side salad with cheese and croutons for lunch": Bacon, cheese, and croutons are all sources of sodium, so this meal would likely not be appropriate for a low-sodium diet unless modifications are made, such as using low-sodium bacon and limiting cheese and crouton amounts.

D. "I will have a baked potato with broiled chicken for dinner": This statement indicates an understanding of choosing low-sodium options. Baked potatoes and broiled chicken are generally low in sodium, especially if prepared without added salt or high-sodium seasonings. This choice aligns well with a low-sodium diet for someone with heart failure.

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The nurse receives a client from the post-anesthesia unit with a new onset of sinus tachycardia and a heart rate of 118 beats per minute. To which reasons does the nurse relate the increased heart rate? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1712.32"]

Explanation

A client with heart failure is placed on a low-sodium diet. Which statement by the client indicates that the nurse's nutritional teaching plan has been effective?

Correct Answer is D

Explanation

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